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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004964
Report Date: 01/28/2025
Date Signed: 04/17/2025 05:44:44 PM

Document Has Been Signed on 04/17/2025 05:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SKOBA, SVITLANAFACILITY NUMBER:
414004964
ADMINISTRATOR/
DIRECTOR:		SKOBA, SVITLANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 445-1385
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
01/28/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:25 AM
MET WITH:Svitlana SkobaTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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***** THIS IS AN AMENDED REPORT FROM ORIGINAL DATED 01/28/2025 *****

On January 28, 2025 @ approx. 11:25am, Licensing Program Analyst (LPA) Maria Olguin-Leon conducted an unannounced, plan of correction (POC) visit and met with license, Svitlana Skoba. Present during today’s visit were licensee, two helpers, and 8 children (2 infants and 6 preschoolers). LPA toured facility for health and safety hazards.

During today’s visit, LPA reviewed LIC9224 Acknowledgement of Receipt of Licensing Reports, which were signed and incomplete for 7 enrolled children. LPA discussed missing information on LIC9224, which must be completed.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with licensee, Svitlana Skoba. Report was translated in Russian by agent #39576975. Appeal Rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Carol Marcroft
NAME OF LICENSING PROGRAM ANALYST: Cindy Interiano
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/28/2025 01:44 PM - It Cannot Be Edited


Created By: Maria Olguin-Leon On 01/28/2025 at 12:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SKOBA, SVITLANA
FACILITY NUMBER: 414004964

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
01/29/2025
Section Cited
HSC
1596.8595(a)(1)

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1596.8595(a)(1) Each licensed child day care facility shall post a copy of any licensing report pertaining to the facility that documents either a facility visit or a complaint investigation that results in a citation for a violation that, if not corrected, will create a direct and immediate risk to the health, safety, or personal rights of children in care. The licensing report provided by the department shall be posted immediately upon receipt, adjacent to the postings required pursuant to Section 1596.817 and on, or immediately adjacent to, the interior side of the main door to the facility and shall remain posted for 30 consecutive days.

This requirement has not been met as evidenced by:
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Helper (H1) posted report dated 01/16/2025 to bulletin board by front door. Deficiency will be cleared as of today.
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Based on observation and interview, licensee did not comply, as LIC 809 Facility Evaluation Report and LIC 809-D issued on 01/16/2025 was not posted in facility or available for parents to review, which poses an potential health and safety risk to children in care.
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An immediate civil penalty of $100 has been assessed.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Marie Rodriguez
LICENSING EVALUATOR NAME:Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
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